All things considered, that September found William Henry Welch in a satisfied state of mind. The Johns Hopkins physician-scientist was Lieutenant-Colonel Welch now, having responded to the call of a country gearing up for war.

The previous weeks had passed in an inspection tour of hastily assembled military camps around the country, where he had been treated with the deference due a man who was serving, simultaneously, as president of the National Academy of Sciences, the Rockefeller Institute and the Carnegie Institution.

Welch had done what he could. “The medical service of the army is now well organized,” he wrote, “and conditions are very much improved in our camps.”

Historic headlines from the Baltimore News, 1918

Thinking his work largely done, Welch mused about resigning from the army. He wanted to devote all his energies to the opening of a new School of Hygiene and Public Health at Hopkins. At the end of his inspection tour, he indulged himself with a few days in the North Carolina hills.

“It is a delightful, restful, quiet place,” he wrote on September 19. Those days at the Mountain Meadows Inn would be the last bit of peace Welch would enjoy for some time. On September 22, he was ordered to Massachusetts, where a strange, virulent influenza had taken hold at Camp Devens. The year, of course, was 1918.

No matter how many times the numbers get trotted out, they seem beyond comprehension. The global death toll from the 1918 flu was long pegged at 20 million, but most experts now think that grossly low. They talk of 50 million, perhaps 100 million.

“If you’re in the business of infectious disease epidemics, you can’t ignore the 1918 flu—it’s the granddaddy of them all,” says the Bloomberg School’s Donald Burke, professor of International Health.

Yet much about the pandemic remains unsettled, particularly the mystery surrounding the shape of the flu’s devastation. In a normal flu epidemic, a graph of fatalities looks like the letter U, with the twin peaks representing a heavy toll among young children and the frail elderly. That graph of the 1918 flu looks more like a misshapen W, with an astonishing middle peak reflecting that it was most fatal to perfectly healthy adults in their 20s and 30s.

Burke and Derek Cummings, a PhD candidate in International Health, are looking at yet another murky area: How, precisely, did the disease travel through the population? Did it follow patterns that correspond with age or ethnic group or social class? Did it take a predictable path from inner city to outer, from urban center to rural outpost, from military camp to civilian population?

Such questions are not academic in a post–September 11 world. The National Institutes of Health is financing this research as one of its MIDAS (Models of Infectious Disease Agent Study) projects to help prepare for biological warfare. But the import of the work goes beyond national security.

“Of all the potential infectious disease threats, I worry about this one more than any other,” Burke says. “When it comes to the probability of a pandemic of flu, I think everyone would say, ‘It’s not if, it’s when.’

“Where is the next virus going to come from? The three possibilities are a natural emergence, bioterrorism and what I call biobungling—that’s when somebody in a lab messes up. There are flu viruses sitting around in who-knows-how-many freezers today. Some of those viruses are extinct—they should be high-containment agents. Yet they’re sitting around, unlocked. If I had to choose which of the possibilities was most likely, I’d go with biobungling.”

Camp Devens was a nightmare of rasping blue death. Lines of men clutching blankets stood outside the hospital in the rain. Inside, cots overflowed into hallways and onto porches. Many patients had the deadly hue of cyanosis, a blue so deep that many observers misjudged this for the return of “black death.” In the morgue, Welch and Cole had to step over and around piles of corpses to observe an autopsy.

Cole later recalled: “When the chest was opened and the blue swollen lungs were removed and opened, and Dr. Welch saw the wet, foamy surfaces with real consolidation, he turned and said, ‘This must be some new kind of infection or plague,’ and he was quite excited and obviously very nervous... It was not surprising that the rest of us were disturbed, but it shocked me to find that the situation, momentarily at least, was too much even for Dr. Welch.”

The physicians quickly recovered their equilibrium. Welch called in an expert from Harvard to perform autopsies. He ordered a Rockefeller lab scientist to drop everything and make a vaccine. He told the army to order camp hospitals expanded and to impose quarantine measures.

It was too little, too late. Flu victims were contagious for several days before showing symptoms, and soldiers had been flowing in and out of Devens daily, as had civilian staff and volunteers. The influenza virus soon appeared in Boston, in Philadelphia, in New York and in New Orleans.

Most victims recovered, and their experience generally was a more intense version of the expected weeklong course of fever, aches, chills and nausea. But a substantial minority endured much worse. They were utterly incapacitated by exhaustion, able to summon up the energy only to cry out constantly in the face of excruciating earaches and headaches.

As the disease progressed and pneumonia set in, they began to bleed profusely—from the nose, the ear and the mouth. Some still recovered. Hopkins physician Harvey Cushing was one such case. But if cyanosis appeared, physicians treated patients as terminal. Autopsies would show a disease that ravaged almost every internal organ.

Baltimore had scant warning that this flu was coming. On September 18 the Baltimore News reported the appearance of “Spanish flu” in New England.

In a flash, the flu was at Fort Meade and at Camp Holabird. A week later, it had hit the city. The News, in a Sept. 29 editorial: “While there is undoubtedly danger of its proving fatal in some cases, there is little likelihood of its being comparable with the plagues... in past centuries.”

With benefit of hindsight, it’s easy to see here the crux of a critical problem in the weeks ahead. There was a war on, and, right or wrong, the war would take priority. Shipyards had to keep working, troop ships had to keep moving, and homeland morale had to stay high. Politicians, the media and even public health officials either couldn’t or wouldn’t communicate frankly. (more)